CC: Diarrhea
HPI: The patient is a 42 year-old male who has a history of borderline HLD, who arrives to the ED with complaints of diarrhea,
... [Show More] lightheadedness, “cottonmouth,” fever, poor appetite, diaphoresis, malaise, and crampy abdominal pain for the past three days after arriving home from a business trip in Chicago. Physical exam demonstrated poor skin turgor, tachycardia, orthostatic hypotension, dry mucous membranes, and a positive guaiac with rectal exam.
Leukocytosis present. Stool culture positive for salmonella enteritidis. C-diff test negative. Stool gram stain depicted gram negative bacilli. Fecal leukocytes >10,000. Colon biopsy cancelled due to identification of infectious etiology.
The patient denies any nausea, vomiting,chest pain, or sob.
Onset: RIght before the diarrhea started about three days ago after a business trip to Chicago. Had a decreased appetite after, but attributed it to overeating.
Location: Abdomen
Duration: Constant
Characteristics: Sharp crampy pain
Associated signs and symptoms: poor appetite, lightheadedness, fever, diaphoresis, and malaise.
Timing:Three days ago
Exacerbating/ relieving factors: Pain is exacerbated when the episodes of diarrhea occur. Decreased pain after diarrhea.
Current Medications: Kaopectate
Allergies: NKDA
PMHx: Chicken pox, borderline HLD
Soc Hx: Married with two children. Drinks one glass of red wine 3-4 days a week. He does not drink or use any recreational drugs.
Fam Hx: Father has HTN. Mother has no issues.Unaware of grandparents history
General: Appears diaphoretic and in discomfort
HEENT: Headache present. Lightheaded. No double vision, or eye trauma. No recent hearing
loss or changes. Denies nasal congestion, post nasal drip, or nose bleeds. Maintains that all teeth are intact, with no ulcers, tooth problems, or bleeding gums. No hoarseness or sore throat. Hearing loss.
Integument: No lesions or rash
Neck: No prior injuries or issues with pain.
Respiratory: No cough, dyspnea, or shortness of breath.
CV: She does not have any known murmurs or palpitations. No known arrhythmias. No exercise intolerance.
GI: No nausea. Abdominal pain and tenderness. No heartburn, nausea, vomiting, or indigestion. Abdominal distention. No history of constipation. Normal weight. Diarrhea. Lack of appetite.
GU: NO known dribbling, urgency, or frequency.
MS: No known joint pain, swelling, arthritis, or muscle pain outside of the chest pain. Full range of motion. No traumas or fractures.
Hematologic: No bleeding, bruising, or anemia.
Lymphatics: No lymph node enlargement. No history of splenectomy.
Psych: No history of anxiety, paranoia, and depression. No history schizophrenia or bipolar. No history of suicide or homicide.
Neuro: No history of a loss of consciousness, weakness or fainting. Headaches. No memory loss and confusion. Denies gait changes. No history of falls.
Endocrine: The patient does not suffer from heat/cold intolerances. No hormone therapies or endocrine symptoms.
Allergic/Immunologic: NKDA.
Physical exam:
Vital Signs: BP 94/50 | Pulse 102 | Temp (Src) 101.5 (Oral) | Resp 14 | Ht 5' 11" | Wt 180 lb,
General: Appears distressed and diaphoretic
HEENT: PERRLA/EOMI, no nasal drainage, head is normocephalic, symmetrical, atraumatic, dry mucous membranes. Oropharynx and external ears unremarkable. Normal conjunctiva.
Neck: No palpable masses. Supple, symmetrical, trachea midline. No thyromegaly or lymphadenopathy
Chest/Lungs: Normal breath sounds. Chest rises symmetrically. Normal breath sounds. Normal respiratory effort. No accessory muscle usage. No cough present.
Heart/Peripheral Vascular: Tachycardia. Normal S1/S2. No murmurs. No JVD noted. Radial pulses +2. Normal capillary refill in toes.
ABD: Hyperactive bowel tones. Moderate distention. Abdominal tenderness. No masses noted. No rebound tenderness. No recent weight loss. Diarrhea. Positive guiac with rectal exam
Musculoskeletal: muscle strength equal, and intact in bilateral upper and lower extremities. No bone deformities. No peripheral edema
Neuro: Cranial nerves 2-12 noted to be intact. Normal deep tendon reflexes.
Skin/Lymph Nodes: No mottling. Moderate skin turgor, some tenting, no other blemishes. No clubbing present. No palpable lymph nodes. No bruises, rashes, or petechial on exposed skin
Primary Diagnosis:
Status/Condition: Infectious colitis secondary to salmonella enteritidis enterocolitis Code Status: Full code
Admit to Unit: Medical unit Activity Level: Stand by assist Diet: Clear liquids
IVF:
● Two liter fluid bolus
● LR at 125 ml/hr continuous
Critical Drips
● None
Respiratory:
● Keep O2 saturation >90%
Diagnostic/Laboratory results: [Show Less]